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A client has a transsphenoidal hypophysectomy to remove a pituitary tumor. When the client returns to the nursing unit following surgery, the head of the bed is elevated 30 degrees. What is the primary purpose for placing the client in this position?
- A. To promote respiratory effort
- B. To reduce pressure on the sella turcica
- C. To prevent acidosis
- D. To promote oxygenation
Correct Answer: B
Rationale: Elevating the head 30 degrees reduces pressure on the sella turcica, minimizing the risk of cerebrospinal fluid leakage post-hypophysectomy.
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When given the news, the client denies the diagnosis and becomes angry, stating there has been a mistake in the tests. Which nursing action is most appropriate at this time?
- A. Emphasizing the importance of treatment
- B. Reassuring the client that the disease is easily managed
- C. Explaining that many people live with diabetes
- D. Listening as the client expresses current feelings
Correct Answer: D
Rationale: Listening to the client's feelings supports emotional processing and acceptance of the diagnosis.
The nurse is providing teaching to multiple clients. Which client should the nurse determine would benefit if the following illustration were utilized when teaching?
- A. The client with hyperthyroidism
- B. The client with diabetes mellitus
- C. The client with Addison's disease
- D. The client with Cushing's syndrome
Correct Answer: D
Rationale: Clinical manifestations of Cushing's syndrome, such as moon face and fat pads, match the illustration.
Which signs/symptoms indicate the client with hypothyroidism is not taking enough thyroid hormone?
- A. Complaints of weight loss and fine tremors.
- B. Complaints of excessive thirst and urination.
- C. Complaints of constipation and being cold.
- D. Complaints of delayed wound healing and belching.
Correct Answer: C
Rationale: Constipation and cold intolerance indicate persistent hypothyroidism due to inadequate thyroid hormone. Weight loss/tremors, thirst, and healing/belching are unrelated.
Which statement by the client about foot care indicates a need for further teaching?
- A. I need to inspect my feet daily.
- B. I should soak my feet each day.
- C. I need to wear shoes whenever I'm not sleeping.
- D. I need to schedule regular appointments with the podiatrist.
Correct Answer: B
Rationale: Soaking feet can lead to skin breakdown in diabetic clients; feet should be washed and dried carefully.
The nurse is caring for the client with Addisonian crisis. Which clinical change should indicate to the nurse that the therapy is effective?
- A. Increase of 25 mm Hg in the client's blood pressure
- B. Decrease of 25 mm Hg in the systolic blood pressure
- C. Increase in serum potassium from 3.4 to 5.8 mEq/dL
- D. Decrease in serum sodium from 146 to 136 mEq/L
Correct Answer: A
Rationale: An increase in BP indicates effective therapy by correcting hypotension from sodium and water depletion.